In Sickness and in Health: An Analysis of Surgical Resident Operative Autonomy Outcomes Based on American Society of Anesthesiologists Classification

Abstract

INTRODUCTION: Resident operative autonomy has progressively decreased and one of the common causes cited is patient safety. The American Society of Anesthesiologists (ASA) score is based on the patient comorbidities and has strong predictive power for morbidity and mortality. The goal of this study was to compare the surgical outcomes by ASA class in relation to resident operative autonomy. METHODS: Using the VA Surgical Quality Improvement Program database, we examined all operative cases of all surgical specialties at teaching VA hospitals from 2004 to 2019. Level of resident operative supervision is prospectively recorded: attending primary surgeon with or without a resident assistant (AP), resident surgeon with attending scrubbed (AR), and resident primary without attending scrubbed (RP). Within each ASA class, the rates of autonomy, composite morbidity, and 30-day mortality were compared. RESULTS: Of 1,344,871 total cases, 141,214 (10.5%) were RP. RP rates decreased with increasing ASA: ASA 1 13%, ASA 2 11.5%, ASA 3 10.3%, ASA 2 10.3%, and ASA 4/5 9.0% (p < 0.001). Overall mortality and morbidity increased with increasing ASA. For each ASA class, there was either no difference or lower morbidity and mortality rates in RP compared to AP and/or AR (Figure).CONCLUSION: Residents are afforded less resident operative autonomy in patients with increasing perioperative risk, which demonstrates appropriate judgement of teaching attendings. Resident autonomous cases did not have worse outcomes regardless of ASA class. In appropriately selected patients, allowing resident operative autonomy is safe even in patients with significant comorbidities.